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Outcomes of in-hospital cardiac arrest in patients with COVID-19 in New York City

      Cardiopulmonary resuscitation (CPR) in patients with in-hospital cardiac arrest (IHCA) has been associated with poor overall survival and neurologic recovery.
      • Girotra S.
      • Nallamothu B.K.
      • Spertus J.A.
      • Li Y.
      • Krumholz H.M.
      • Chan P.S.
      Trends in survival after in-hospital cardiac arrest.
      The coronavirus 2019 (COVID-19) global pandemic carries a high mortality rate with high risk of cardiopulmonary arrest.
      • Richardson S.
      • Hirsch J.S.
      • Narasimhan M.
      • et al.
      Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.
      Clear policies for crisis standards of care and CPR are essential in light of limited Intensive Care Unit (ICU) resources and aerosolized transmission among code team members.
      • Kramer D.B.
      • Lo B.
      • Dickert N.W.
      CPR in the Covid-19 era – an ethical framework.
      There is limited literature regarding the survival outcomes and effectiveness of CPR in patients with COVID-19 who suffer cardiac arrest.
      • Shao F.
      • Xu S.
      • Ma X.
      • et al.
      In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China.
      Here, we describe our experience with performing CPR in patients with COVID-19 who developed IHCA.
      This retrospective case series included patients 18 years of age or older with confirmed COVID-19 who subsequently had an IHCA between March 1st and May 18th, 2020, at a 500-bed teaching hospital in Manhattan. COVID-19 cases were confirmed using a reverse-transcriptase polymerase chain reaction assay. Data were manually abstracted from electronic health records with the use of a standardized abstraction process. We identified 31 patients who met the inclusion criteria. Patients were grouped based on whether they suffered a cardiac arrest in ICU or non-ICU setting.
      Of the 31 patients, the median age was 69 (IQR 57–76) years, 71% were male, and 55% had cardiovascular disease (Table 1). 24 patients (77%) developed IHCA in the ICU and 7 (23%) in a non-ICU setting. The initial rhythm was PEA in 18 (58%) patients, asystole in 9 (29%) patients, and ventricular tachycardia or fibrillation in 4 (13%) patients. 18 (58%) patients were on mechanical ventilation before the arrest. The median PaO2/FiO2 (P/F) ratio was 77 (IQR 61–123), with a higher SOFA score in ICU patients versus non-ICU (12 vs. 4, p = 0.01). Patients in non-ICU settings had higher median inflammatory markers and serum creatinine levels, however this did not reach statistical significance. The median resuscitation time was 14 minutes (IQR 8–20). 13 (42%) patients survived the initial cardiac event, of which 12 were in an ICU setting. Of the total 31 patients, none survived to hospital discharge. The median survival time until death was 2.8 h (IQR 1.5–13.3).
      Table 1Characteristics of 31 COVID-19 patients with In-Hospital Cardiac Arrest (IHCA).
      CharacteristicTotal (N = 31)Non-ICU (N = 7)ICU (N = 24)p-value
      Median age (IQR – yr)69 (57–76)69 (57–77)69 (56–76)0.77
      Male sex – no. (%)22 (71)6 (86)16 (67)0.64
      Median body mass index26.9 (23–31)25.0 (21–29)27.4 (24–33)0.29
      Race or ethnic group – no. (%)
       White8 (26)2 (27)6 (25)1.00
       African American13 (42)4 (57)9 (38)0.40
       Hispanic6 (19)1 (14)5 (21)1.00
       Asian2 (6)0 (0)2 (8)1.00
       Other2 (6)0 (0)2 (8)1.00
      Comorbidities – no. (%)
       Heart disease17 (55)7 (100)10 (42)0.01
       Diabetes mellitus13 (42)3 (38)10 (43)0.67
       Chronic kidney disease6 (19)3 (43)3 (13)0.11
       End stage renal disease3 (10)0 (0)3 (12.5)1.00
       Asthma or chronic obstructive pulmonary disease13 (42)2 (29)11 (46)0.67
       Venous thromboembolism2 (6)1 (14)1 (4)0.41
       Cancer5 (16)1 (14)4 (17)1.00
      Median laboratory values on admission – (IQR)
       Absolute lymphocyte count – K/uL0.85 (0.7–1.1)0.7 (0.5–1.1)0.9 (0.7–1.4)0.30
       Creatinine – mg/dL1.3 (0.9–7.0)7.0 (1.3–8.7)1.1 (0.8–1.9)0.06
       Ferritin – ng/ml1322 (814–3398)2698 (1317–6349)1232 (764–2929)0.17
       C-reactive protein – mg/L199 (73–253)238 (73–245)183 (73–260)0.77
       Lactate dehydrogenase – U/L772 (465–1243)1258 (1160–2458)685 (463–9630.06
       D-dimer – mg/ml0.95 (0.35–2.48)2.6 (1.40–3.54)0.83 (0.35–2.07)0.04
       Interleukin 6 – pg/mL92 (48–206)255 (96–1046)87 (48–179)0.32
       Lactate – mmol/L1.2 (0.8–1.6)1.2 (0.9–1.6)1.3 (0.8–1.6)0.87
      Median laboratory values on day of IHCA – (IQR)
       Absolute lymphocyte count – K/μL0.65 (0.3–0.9)0.6 (0.5–1.9)0.7 (0.4–0.9)0.35
       Creatinine – mg/dL3.0 (1.0–6.3)3.0 (1.0–7.4)3.0 (1.0–5.0)0.39
       Ferritin – ng/ml2137 (1078–4462)4003 (1317–8876)2111 (918–3172)0.18
       C-reactive protein – mg/L171 (64–286)207 (171–240)111 (64–294)0.45
       Lactate dehydrogenase – U/L915 (692–1131)1026 (597–2458)914 (704–1097)0.78
       D-dimer – mg/ml3.75 (2.63–8.92)6.24 (3.64–10.82)3.38 (2.26–8.13)0.26
       Lactate – mmol/L2.8 (1.7–9.8)3.4 (1.7–8.1)2.8 (1.07–9.8)1.00
      Treatment for COVID-19 – no. (%)
       Corticosteroids24 (77)3 (43)21 (88)0.03
       Azithromycin28 (90)5 (7)23 (96)0.56
       Hydroxychloroquine26 (84)4 (57)22 (92)0.06
       Therapeutic anticoagulation20 (65)2 (29)18 (75)0.07
       Anti-interleukin-613 (42)1 (14)12 (50)0.19
       Convalescent plasma3 (9.68)0 (0)3 (13)1.00
       Remdesivir1 (3.23)0 (0)1 (4)1.00
      Oxygen delivery at time of IHCA – no. (%)
       Low-flow nasal cannula2 (6)1 (14)1 (4)0.40
       Non-rebreather1 (3)1 (0)0 (0)0.23
       Non-invasive ventilation6 (19)2 (29)4 (17)0.60
       High-flow nasal cannula4 (13)1 (14)3 (13)1.00
       Mechanical ventilator18 (58)2 (29)16 (67)0.09
      Severity of illness markers at time of IHCA
       P/F ratio – median (IQR)77 (61–123)153 (68–263)72 (59–114)0.12
       Sequential Organ Failure Assessment (SOFA) Score – mean (SD)9 (4–13)4 (3–5)12 (5.5–14)0.01
      Characteristics of IHCA
      Initial rhythm – no. (%)
       PEA18 (58)5 (71)13 (54)0.70
       Asystole9 (29)1 (14)8 (33)0.60
       VF/VT4 (13)1 (14)3 (13)1.00
      ROSC20 (65)3 (43)17 (71)0.20
      Shock delivered7 (23)3 (43)4 (17)0.30
      Survived cardiac event (>20 min)13 (42)1 (14)12 (50)0.20
      Median arrest time (IQR – min)14 (8–20)12 (10–21)15 (7–19)0.40
      Etiology of arrest – no. (%)
       Respiratory24 (77)7 (100)17 (71)0.16
       Metabolic5 (16)0 (0)5 (21)0.56
       Cardiac2 (6)0 (0)2 (8)1.00
      Characteristics of hospital stay (IQR – days) median
       Hospital LOS13 (5–12)5 (2–9)14 (11–22)0.003
       Intensive care unit LOS5 (1–14)0.011 (2–15)<0.001
       Ventilator days2 (1–9)1 (0–1)5 (1–12)0.003
       Admission to cardiac arrest12 (4–16)4 (1–8)13 (10–19)0.003
      Survived cardiac event to mortality (IQR – hours) median2.8 (1.5–13.3)1.2 (1.2–1.2)3.7 (1.6–13.7)0.28
      Mortality31 (100)7 (100)24 (100)
      In this series of patients with COVID-19 who suffered IHCA, there was a high prevalence of respiratory etiology of arrest, low P/F ratio, and extremely poor prognosis. The most frequent underlying comorbidity was cardiovascular disease, which is consistent with reports globally. Despite an initial survival rate of 42% in our case series, the overall mortality was 100%, with very short-term survival until death in those individuals who achieved ROSC. The findings of low P/F ratio and high SOFA scores demonstrate the severity of illness in these patients with COVID-19 that suffered IHCA, and speaks to their poor prognosis. Further research is necessary to understand whether these poor outcomes after IHCA can be extrapolated to the larger population of patients with COVID-19 and guide institutional policies around cardiopulmonary resuscitation.

      Conflict of interest

      None declared.

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